Interventions promoting healthy eating as a tool for reducing social inequalities in diet in low- and middle-income countries: a systematic review

Barriers to consumption of fruits and vegetables and strategies to overcome them in low- and middle-income countries: a narrative review

This review provides an overview of the barriers to the consumption of fruits and vegetables (FVs) as well as strategies to improve the intake of FVs in low- and middle-income countries (LMICs). The importance of the consumption of FVs and its role in disease prevention are discussed briefly. Trends in the consumption of FVs in LMICs are also summarised. The WHO recommends that every individual should consume at least five servings or 400 grams of FVs per day. Epidemiological and clinical investigations have demonstrated that FVs contain numerous bioactive compounds with health-protecting activities. Despite their health benefits, the intake of FVs in LMICs remains low. Major barriers identified were socio-demographic factors, environmental conditions, individual and cultural factors, and macrosystem influences. These barriers may be lowered at the household, school, community, and national level through multi-component interventions including behaviour change communication (BCC) initiatives, nutrition education (NE), gardening initiatives, farm to institution programs (FIPs), food baskets, cash transfers, nutrition-agriculture policy and program linkages, and food-market environment-based strategies. This review has research implications due to the positive outcomes of strategies that lower such barriers and boost consumption of FVs in LMICs.

Wealth and Sedentary Time Are Associated With Dietary Patterns Among Preadolescents in Nairobi City, Kenya

OBJECTIVE

The study aimed to compare dietary patterns in preadolescents in urban areas with different physical activity and socioeconomic profiles in Nairobi, Kenya.

DESIGN

Cross-sectional.

PARTICIPANTS

Preadolescents aged 9-14 years (n = 149) living in low- or middle-income areas in Nairobi.

VARIABLES MEASURED

Sociodemographic characteristics were collected using a validated questionnaire. Weight and height were measured. Diet was assessed using a food frequency questionnaire and physical activity by accelerometer.

ANALYSIS

Dietary patterns (DP) were formed through principal component analysis. Associations of age, sex, parental education, wealth, body mass index, physical activity, and sedentary time with DPs were analyzed with linear regression.

RESULTS

Three DPs explained 36% of the total variance in food consumption: (1) snacks, fast food, and meat; (2) dairy products and plant protein; and (3) vegetables and refined grains. Higher wealth was associated with higher scores of the first DP (P < 0.05).

CONCLUSIONS AND IMPLICATIONS

Consumption of foods often deemed unhealthy (eg, snacks and fast food) was more frequent among preadolescents whose families were wealthier. Interventions that seek ways to promote healthy lifestyles among families residing in urban areas of Kenya are warranted.

Supermarket promotions in Western Sweden are incompatible with Nordic dietary recommendations and differ by area-level socioeconomic index

BACKGROUND

Large supermarket chains produce weekly advertisements to promote foods and influence consumer purchases. The broad consumer reach of these ads presents an opportunity to promote foods that align with dietary recommendations. Thus, the aim of this study was to investigate the health quality of supermarkets' weekly food promotions in a large region of Sweden with attention to more and less advantaged socioeconomic index areas.

METHODS

Analysis of weekly advertisements from 122 individual stores, representing seven chains, was carried out in a large region of Sweden from 2-29 March in 2020. Food promotions were divided into categories according to the Nordic Nutrition Recommendations and World Health Organization Regional Office for Europe's nutrient profile model, and defined as 'most healthy', 'healthy', 'unhealthy' and 'most unhealthy'. A mean socioeconomic index was used to classify each store location to determine whether proportions of the 'most unhealthy' foods differed between more advantaged and more disadvantaged socioeconomic index areas.

RESULTS

In total, 29,958 food items were analyzed. Two-thirds of promotions belonged to the food groups considered 'most unhealthy' and 'unhealthy'. In the 'most unhealthy' food group 'sugar-rich beverages and foods' constituted approximately 23.0% of the promotions. Food promotions had 25% increased odds to be from the 'most unhealthy' group (odds ratio 1.25, confidence interval 1.17, 1.33) in more disadvantaged socioeconomic index areas. This association could be explained by the supermarket chain the stores belonged to.

CONCLUSIONS

Our findings indicate that Swedish supermarkets promote a large proportion of unhealthy foods as classified by the Nordic Nutrition Recommendations. We also observe that certain national supermarket chains tend to locate their stores in more disadvantaged areas and promote a greater proportion of unhealthy foods in their weekly advertisements compared to the more advantaged areas. There is an urgent need for supermarkets to shift promotions toward healthier food items.

Food profile of Yanomami indigenous children aged 6 to 59 months from the Brazilian Amazon, according to the degree of food processing: a cross-sectional study

OBJECTIVE

The current study aimed to characterise the food profile of Yanomami indigenous children according to the degree of food processing and its associated factors.

DESIGN

This is a cross-sectional study with Yanomami indigenous children aged 6 to 59 months. Socio-demographic, maternal and infant data were collected through a standardised questionnaire. The food profile was obtained by using a list of thirty-four foods to verify the child's consumption of these foods on the day preceding the interview. Foods were classified according to the degree of processing based on the NOVA system (in natura or minimally processed, processed culinary ingredients, processed and ultra-processed). In natura and minimally processed foods were subdivided into 'regional' and 'urban' foods. Poisson regression analysis was applied to estimate the associated factors according to the 90 % CI.

SETTING

Three villages (Auaris, Maturacá and Ariabú) in the Yanomami indigenous territory, in the Brazilian Amazon.

PARTICIPANTS

In total, 251 Yanomami children aged 6 to 59 months were evaluated.

RESULTS

The prevalence of consumption of 'regional' and 'urban' in natura or minimally processed foods was 93 % and 56 %, respectively, and consumption of ultra-processed foods was 32 %. Ultra-processed food consumption was 11·6 times higher in children of Maturacá and 9·2 times higher in Ariabú when compared with the children of Auaris and 31 % lower in children who had mothers with shorter stature.

CONCLUSION

Despite the high frequency of consumption of in natura and minimally processed foods, the consumption of ultra-processed foods was substantial and was associated with demographic and maternal factors in Yanomani indigenous children under 5 years of age.

Inequalities in the use of health services in a municipality in Southern Brazil in 2019: a cross-sectional study

OBJECTIVE

to assess inequalities in the use of health services in a municipality in Southern Brazil.

METHODS

This was a population-based cross-sectional study conducted with adults living in the urban area of the municipality of Criciúma, state of Santa Catarina, Brazil, between March and December 2019; the research outcomes were medical consultation, dental visit, nutritional counseling and the use of the Brazilian National Health System (Sistema Único de Saúde - SUS); the exposures were age, schooling and income; inequalities were analyzed using the Slope index of inequality and equiplots.

RESULTS

A total of 820 individuals were studied; medical consultation was higher (14.2 percentage points [p.p.]), and dental visit was lower (-29.5 p.p.), in older adults, when compared to young people; dental visit (41.1 p.p.) and nutritional counseling (18.0 p.p.) were higher in individuals with higher level of education, when compared to those with lower level of education; the use of SUS was higher in older adults (21.3 p.p.), with lower level of education (-61.2 p.p.) and lower income (-51.6 p.p.), when compared to their peers.

CONCLUSION

in order to develop public policies, these inequalities should be taken into consideration.

Why context matters when changing the diet: A narrative review of placebo, nocebo, and psychosocial context effects and implications for outcome research and nutrition counselling

Placebo (PE) and nocebo effects (NE) have been subjects of systematic research in medicine and psychotherapy for many decades to distinguish between the (specific) pharmacological effect of medication and the (unspecific) effect of the context. Despite this significant research, the awareness, operationalisation, and reflection of the multiplicity of PE, NE, and psychosocial context effects (PSCE) is currently limited when researching outcomes of diet changes in studies without randomisation and placebo control. This neglection is critical as it could systematically influence outcomes by moderating and mediating them and thus reducing the validity and evidence base of these studies. Therefore, we performed a (non-systematic) narrative review (NR) on the following objectives: (1) present a concise overview about the relevance of PE, NE, and PSCE in medicine and nutrition research; (2) review the current state of research on reflecting context effects when studying diet changes; (3) provide useful theoretical foundations via consideration and integration of micro- and macro context effects; (4) operationalise as hypotheses the potential PE, NE, and PSCE which are specific for researching diet changes; and (5) derive their impact for future research as well as for nutrition counselling. The electronic search in this NR for objective (2) identified N = 5 publications and for objective (4) we found N = 61 articles retrieved in the first round of search, additional references were identified by a manual and snowball search among the cited references resulting finally in N = 37. This NR offers a synoptical basis to foster awareness and operationalisation of a variety of PE, NE, and PSCE. Interdisciplinary research teams should monitor these factors using, e.g., qualitative, mixed-method studies, process evaluation, item bank approaches, moderator and mediator analysis that might reveal substantially new insights, and outcomes of relevance to science and nutrition counselling. Nevertheless, the present NR has several limitations, especially as it is non-systematic, because it is a very heterogeneous field of research, in which the topic we are investigating is usually regarded as marginal and subordinate. Therefore, future research should conduct systematic reviews and particularly theory-based primary studies (experimental research) on hypotheses of PE, NE, and PSCE in outcome research in diet changes.

Development and Field-Testing of Proposed Food-Based Dietary Guideline Messages and Images amongst Consumers in Tanzania

In this paper we report on the development and field-testing of proposed food-based dietary guideline (FBDG) messages among Tanzanian consumers. The messages were tested for cultural appropriateness, consumer understanding, acceptability, and feasibility. In addition, comprehension of the messages was assessed using culturally representative images for low literacy audiences. Focus group discussions were used as method for data collection. Results indicate that the core meaning of the proposed FBDG messages and images were understood and acceptable to the general population. However, participants felt that nutrition education would be required for improved comprehension. Feasibility was affected by some cultural differences, lack of nutrition knowledge, time constraints, and poverty. Suggestions were made for some rewording of certain messages and editing of certain images. It is recommended that the field-tested messages and images, incorporating the suggested changes, should be adopted. Once adopted, the FBDGs can be used to inform and engage various stakeholders, including parents, caregivers, healthcare providers and educators on appropriate nutritional practices for children and adults. They can also be used to guide implementation of relevant policies and programmes to contribute towards the achievement of sustainable healthy diets and healthy dietary patterns.

Healthy eating strategies for socioeconomically disadvantaged populations: a meta-ethnography

Purpose: In developed countries, diet-related health inequalities between people with different levels of socioeconomic advantage persist. However, there is limited qualitative evidence to inform the design of effective healthy eating (HE) strategies in socioeconomically disadvantaged populations (SDPs). The purpose of this review was to explore the characteristics influencing HE strategies for SDPs and develop a new understanding of how and why they influence their success.

Methods: A qualitative evidence synthesis using a systematic meta-ethnographic approach. The twelve studies included were conducted in the USA, Canada, Australia, and UK.

Results: The studies described a range of HE strategies, including nutrition education programs, food vouchers, and community gardens. Personal values and sense of pride and autonomy were found to have an influence on participants’ attitudes towards HE strategies. Similarly, social characteristics such as level of social support and opportunities for shared benefits influenced participants’ engagement. Structural characteristics such as the affordability and accessibility of healthy foods determined strategy acceptability and success. Finally, organizational characteristics such as flexibility influenced how well strategies supported the circumstances of participants.

Conclusions: These overlapping characteristics may be used to inform the development, implementation, and evaluation of strategies to improve healthy eating in SDPs.

Socioeconomic Inequalities in Food Consumption: A Cross-Sectional Study in Portuguese Adults

<b><i>Background:</i></b> Food is a major determinant of chronic noncommunicable diseases. Because of this, social inequalities in food consumption will likely produce social inequalities in disease and life expectancy. <b><i>Objectives:</i></b> This study analyses the social inequalities in food consumption in Portugal and whether they differ between men and women and between younger and older people. <b><i>Methods:</i></b> Following a cross-sectional observational study, we analyzed data from 11,085 individuals aged 25–64 years who participated in the 2014 National Health Interview Survey (NHIS). Logistic regression models were used to measure the association between socioeconomic conditions, i.e., education and income, and food consumption. The analysis was then stratified by sex and age. <b><i>Results:</i></b> A positive gradient for income and education was observed in the consumption of fish, cakes, natural juices, and dairy products. The consumption of legumes and soft drinks was inversely related to income and education. A socioeconomic gradient for fruits and vegetables was observed only among women and older people. Worse-off people consumed less soup, and underprivileged women consumed fewer fast-food products. <b><i>Conclusion:</i></b> The food consumption patterns of Portuguese adults are related to their socioeconomic condition, with few variations across demographic categories.

Demographic, Anthropometric and Food Behavior Data towards Healthy Eating in Romania

Background: Each country has specific social, cultural, and economic characteristics regarding the motivations for improving health. The aim of this study was to evaluate demographic characteristics, anthropometric data, and elements related to food behavior and health, as well as Romanians’ motivations towards healthy eating. Methods: This is a descriptive cross-sectional questionnaire based study enrolling 751 Romanian participants, which was carried out in in 2017–2018. Results: We obtained a positive correlation between age and Body Mass Index, and this was maintained also when we analyzed the two genders separately, being, however, even stronger for women. The number of hours/day spent watching TV or in front of the computer was positively correlated with both age and BMI. In general, with aging, there is an increasing concern regarding the practice of a healthy diet. The higher education level was significantly associated with healthier choices. Conclusions: The study of the three dietary dimensions, food properties, health attitudes, and dietary behavior, vis-à-vis various disorders revealed that the group most concerned of their diet was those who suffered from cardiovascular disorders.

Effectiveness of Interventions to Promote Healthy Eating Habits in Children and Adolescents at Risk of Poverty: Systematic Review and Meta-Analysis

The objective of this review was to provide an up-to-date review of trials that include behavioral intervention on the eating habits of children and adolescents at risk of poverty, applying meta-analysis to estimate the size of the intervention effect. A systematic literature search was performed in the following databases: MEDLINE via Pubmed and via EBSCOhost, LILACS and IBECS via VHL. The MeSH terms were used: "social class", "poverty", "diet", "health promotion" (PROSPERO ID: 183900). A total of 14 articles were finally included in this systematic review. The primary results of the included studies were meta-analyzed with the RevMan 5.3 program, assuming a random effects model. Analysis of the overall effect showed combined standardized mean differences (SMD) of 0.16 (CI 95%: [0.03, 0.30], I² = 76%). The p-value for the Z statistic was 0.02, which reflects accuracy in the effect estimation. When establishing subgroups based on the intervention tracking time points, studies that provided longer-term follow-up data showed a combined SMD of 0.15 (CI 95%: [-0.02, 0.32], I² = 81%]). Small effects of behavioral interventions were found to promote healthy eating habits, but better effects were shown in cases where the invention was followed up in the long term.

Effect of Integrated Pictorial Handbook Education and Counseling on Improving Anemia Status, Knowledge, Food Intake, and Iron Tablet Compliance Among Anemic Pregnant Women in Indonesia: A Quasi-Experimental Study

Purpose

To determine the effect of individual education through a pictorial handbook on anemia in conjunction with counseling on improving hemoglobin and hematocrit level, birth weight, knowledge, iron-rich food and iron-folic acid (IFA) intake.

Patients and Methods

The study developed a pictorial handbook that was conceptualized based on the Health Belief Model and adjusted to some cultural and local contexts. A quasi-experimental pre-test–post-test control group design was used, purposefully conducted between two homogenous municipalities, each having a rate of anemic pregnancy that was 40% or greater. The sample consists of 140 anemic pregnant women randomly allocated via lottery into two groups; the intervention group (n=70), which received two home visits—one for education and another for a counseling session, and control group (n=70), which received routine antenatal care. A chi-square test and a Mann–Whitney U-test were conducted to compare the baseline socio-demographics. An analysis of covariance (ANCOVA), controlling some possible confounders, was performed to analyze the effect of intervention.

Results

The post-test means of hemoglobin F (1, 132) = 122, p-value <0.001, and hematocrit levels F (1, 132) = 373, p-value <0.001, were significantly different and higher in the intervention group compared to the control group. Similar results were found in knowledge, food frequency score, number of IFA intake (with p-value <0.001), birth weight and daily iron intake from food (with p-value <0.05). The intervention had a particularly large effect on food frequency score and number of IFA intake, and medium effect on hemoglobin and hematocrit levels.

Conclusion

Individual education through a pictorial handbook on anemia in conjunction with the counseling intervention program had a positive impact on hemoglobin and hematocrit levels for anemic pregnant women in their third trimester of pregnancy.

Methodology for developing and evaluating food-based dietary guidelines and a Healthy Eating Index for Ethiopia: a study protocol

INTRODUCTION

Food-based dietary guidelines (FBDGs) are used to promote and maintain healthy eating in a population, by providing country-specific guidance. However, many African countries like Ethiopia do not have FBDGs. This paper describes the methodology for the development of Ethiopian FBDGs and for creating and evaluating a Healthy Eating Index and a scoring tool that can be used to monitor the adherence of the population to FBDGs.

METHODS AND ANALYSIS

A multidisciplinary technical working group will be tasked to develop FBDGs for the general population above 2 years of age based on identification of priority diet-related public health problems and risk factors, and a systematic review of dietary patterns in relation to the identified priority health outcomes, following a multistep process. FBDGs will be translated into daily food choices for specific subpopulations by applying linear programming using data from the National Food Consumption Survey (NFCS) of 2011. FBDGs will be evaluated for cultural appropriateness, acceptability, consumer understanding and practicality. A dietary gap assessment will be conducted by comparing the national food supply with the country's food demand. In addition an Ethiopian Healthy Eating Index (EHEI) will be developed based on the FBDGs using the NFCS data. The EHEI will be evaluated by comparing the EHEI Score based on 24 hours diet recall with that of the EHEI Score based on a Food Frequency Questionnaire, by analysing the association of the EHEI Score with population characteristics and micronutrient intake with or without additional adjustment for energy intake. Finally, a brief Food Quality Screening tool scoring for the important EHEI components will be developed to enable evaluation for counselling.

ETHICS AND DISSEMINATION

Ethical approval is received from the Scientific and Ethical Review Office of the Ethiopian Public Health Institute. The findings will be disseminated through peer-reviewed publications.A dissemination workshop will be organised with key implementing sectors of the food system for a healthier diet (http://a4nh.cgiar.org/our-research/research-flagships/) and with key public and private partners. The findings from this study will be translated into FBDGs and shared through conferences, reports and the mass media (TV and radio).

TRIAL REGISTRATION NUMBER

NCT03394963; Pre-results.

"Then you raise them with Shirchoy or cookies": Understanding influences on delayed dietary diversity among children in Tajikistan

Dietary diversity is a key component of infant and young child feeding (IYCF) as well as adult health. In Tajikistan, a predominantly rural, former Soviet country in Central Asia, we conducted formative research to identify barriers to dietary diversity and strategies for nutrition behaviour change. In Spring, 2016, mixed‐methods data collection took place across 13 villages in all five regions, collecting collaborative mapping; structured assessments of stores and markets; home visits for dietary recalls; food storage, preparation, and meal observations; focus groups with pregnant women, mothers of young children, fathers, and mothers‐in‐law; and in‐depth expert interviews with local nutrition and health influentials. Overall, maternal diet was adequate in terms of diversity (only 13% reported <5/10 food groups in the past 24 hr); however, only 42% of index children 6–24 months met WHO guidelines for diversity, and only 34% met minimum acceptable diet criteria. In addition to issues of poverty and food scarcity, qualitative data reveal many behavioural barriers to timely introduction of diverse complementary foods. Women's strategies focused on gradual introduction of household diet components, without regard for diversity or nutrition. Foods such as meat were seen as costly and thus inappropriate for IYCF, and food taboos (i.e., fresh vegetables) further reduced diversity. Infant food preparation methods such as grinding were seen as impractical, and many foods were withheld until children develop teeth. Possible nutrition education strategies include point‐of‐purchase campaigns to improve availability and appeal of IYCF‐friendly foods, as well as influencing other key household members through mosques, schools, and health care providers.

Determinants of inequalities in the quality of Brazilian diet: trends in 12-year population-based study (2003-2015)

Background

Recent studies have explored the influence of socioeconomic inequalities on the diet quality. However, there is lack of evidence regarding the level of inequalities in dietary quality and its main contributing factors from population-based follow-up studies. The primary objective of this study was to investigate the level and the determinants of inequalities in diet quality in a representative sample of adolescents, adults and older adults resident in São Paulo, Brazil.

Methods

Data from the Health Survey of São Paulo (ISA-Capital) were analyzed for 2003 (n = 2398), 2008 (n = 1662) and 2015 (n = 1742) surveys. Information on food consumption was obtained through 24-h dietary recall, and diet quality was assessed based on the Revised Brazilian Healthy Eating Index (BHEI-R). The descriptive variables were compared using 95% confidence interval. The scores of BHEI-R and its components were compared across age groups and year. The association between socioeconomic inequalities and diet quality was based on the estimation of concentration index.

Results

We observed that the BHEI-R scores gradually improved over 12-years, with older adults showing the greatest improvement. The increase in overall population score was observed for total fruits, whole fruits, whole grains, oils and sodium. The main contributor to socioeconomic inequality in diet quality in 2003 was ethnic group, and in 2008 and 2015, it was per capita household income; age was a persistent factor of inequality in the population over the years. Concentration indices indicated that lower income individuals had higher BHEI-R scores in 2003; however, there was a shift in favor of higher income individuals in 2008 and 2015.

Conclusions

Changes in the patterns of determination of inequalities according to age, ethnic group or income during the period analyzed show the existence of ongoing process of contribution of demographic and socioeconomic factors in the diet quality of individuals in a large urban center.